S3495 A Case of Eosinophilic Gastroenteritis in Disguise as a Parasitic Infection

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Introduction: Eosinophilic gastroenteritis (EGE) is a rare inflammatory disorder that can involve any part of the gastrointestinal (GI) tract affecting around 22 per 100000 people. It classically presents with GI symptoms and peripheral eosinophilia. Our case highlights a clinical overlap between eosinophilic gastroenteritis (EGE) and parasitic infection. Case Description/Methods: A 41-year-old man presented with 2 weeks of watery diarrhea and emesis, after a 2-month trip to Latin America. His symptoms started a few days before his return. He reported 10-14 episodes of watery, non-bloody diarrhea daily with intermittent epigastric pain, night sweats, anorexia, nausea, and weight loss. He was given amoxicillin by a relative without avail in addition to taking penicillin two days before presentation for a tooth infection. On his trip, he occasionally drank tap water, had raw vegetables and raw milk but denied having raw meat or fish. He also reported walking barefooted in jungle areas and swimming in lakes, but denied any foot/skin trauma. His medical history is non-contributory. On exam, blood pressure was 99/62 mmHg, with an otherwise normal full exam. Labs showed normal hemoglobin, WBC of 11.4k/ml with eosinophilia, and a Creatinine of 1.35 mg/dl. Abdominal CT with contrast showed colitis of the ascending and proximal transverse colon. He was empirically given ivermectin for Strongyloides with no improvement. Further infectious workup was negative. Endoscopy findings suggested eosinophilic esophagitis, gastritis, erythematous duodenopathy, and an erythematous mucosa in the terminal ileum (Figure 1). Pathology showed active esophagitis, inflammation in the gastric antrum, duodenum, terminal ileum, colon, and markedly increased eosinophils and plasma cells in all locations. He was discharged on albendazole but with no response. He was readmitted and started on a 10-day prednisone 40mg course with improvement leading to discharge. Discussion: The presentation of GI symptoms and peripheral eosinophilia carries a broad list of differential diagnoses including parasitic infections, inflammatory bowel disease, hyper-eosinophilic syndrome, malignancy, and eosinophilic gastroenteritis. This can be challenging at times as it can represent an overlap between multiple etiologies. We decided to treat empirically for Strongyloides given the suspicious travel history and the risk of hyperinfection syndrome, but the lack of response led to a more confident diagnosis of EGE as evident by response to corticosteroids.